Medicare Set-Asides are one of those narrow but very deep niches in the workers comp (and other insurance lines) business that look simple at first glance, but are anything but.
The Federal government, more specifically the Center for Medicare and Medicaid Services (CMS) requires payers to submit MSAs for claims that meet specific requirements.
There’s been a good deal of confusion about reporting requirements, controversy over how to estimate future drug costs, concern over delays in processing MSAs by CMS vendors, and disputes over the vendors’ judgments. A lot of this is inevitable, as MSAs are a fairly recent phenomena governed by CMS’ myriad and sundry rules. But inevitable or not, the confusion and lack of clarity on deadlines, reporting and funding requirements and submission standards are causing significant problems for all involved.
There are currently two efforts to resolve much of the confusion and concern. WorkCompCentral reports a bill has been submitted to the House that addresses many payer (and CMS) issues. According to Safeway Risk Manager Bill Zachry;
“The bill was developed by the Medicare Advisory Recovery Coalition (MARC) to focus primarily on liability issues, but a number of the provisions will also affect insurance carriers and self-insured employers with respect to conditional payments and reporting of workers’ compensation payments and obligations.
The primary features of the proposed bill include:
1. Providing a specific time frame and process to be used in
determining MSP required payments before settlements
2. A right of appeal for Non-Group Health Plans with respect to MSP
obligations
3. Sensible MSP Recovery Thresholds
4. Taking Social Security Numbers (SSN) and Health Insurance Card
Numbers (HICN) Out of the Reporting Process
5. Setting a Statute of Limitation for MSP claims
6. Establishing safe harbors and clarity with respect to MMSEA §111
reporting penalties
7. Establishing a modest user fee designed to assure that the reforms
in the bill do not raise cost issues in the scoring of the bill.”
There are also indications that CMS is listening to vendor complaints, as it has recently extended the deadline for electronic submission to the end of this year. CMS is also looking for vendors to process the MSA submissions, and is asking interested parties to bid on the contract.
Click here for more details or if you’re looking to support MARC’s efforts,
Mar
11
